International Association For Medical Assistance to Travellers

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Immunizations

Required Vaccinations

No vaccinations are required to enter this country.

Recommended Vaccinations

Routine Immunizations

Your trip is a good occasion for a reminder to keep your routine immunizations updated; more than 80% of adults in industrialized countries have not maintained their immunization status. The following vaccinations are recommended for your protection and to prevent the spread of infectious diseases. 

Tetanus, Diphtheria, Pertussis, Measles, Mumps, Rubella, 
Polio should be reviewed and updated if necessary. Note: Many of these vaccine preventable illnesses are making a resurgence due to non-vaccination, incomplete vaccination, and waning immunity. It is important to keep your routine immunizations up-to-date.
 
Seasonal influenza
vaccination is recommended for all travellers over 6 months of age, especially for children, pregnant women, persons over 65, and those with chronic health conditions such as asthma, diabetes, lung disease, heart disease, immune-suppressive disorders, and organ transplant recipients. Note: In the northern hemisphere the flu season typically runs from November to April and from April to October in the southern hemisphere. If the flu vaccine is not available at the time of departure, contact your doctor or travel health clinic regarding influenza anti-viral protection.

Pneumococcal vaccine is recommended for persons over the age of 65 and persons of any age suffering from cardiovascular disease, diabetes, renal disorders, liver diseases, sickle cell disease, asplenia, or immuno-suppressive disorders.

Hepatitis A

The Hepatitis A virus (HAV) is primarily transmitted from person to person via the fecal-oral route and through contaminated water and food - such as shellfish, and uncooked vegetables or fruit prepared by infected food handlers.

Risk: The virus is present worldwide, but the level of prevalence depends on local sanitary conditions. HAV circulates widely in populations living in areas with poor hygiene infrastructure. In these areas, persons usually acquire the virus during childhood when the illness is asymptomatic (but still infective to others) or mild, and end up developing full immunity. Large outbreaks in these countries are rare. In contrast, a large number of non-immune persons are found in highly industrialized countries where community wide outbreaks can occur when proper food handling or good sanitation practices are not maintained including in daycare centres, prisons, or mass gatherings.

Symptoms: In many cases, the infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms will usually get ill between 15 to 50 days after becoming infected. Symptoms include malaise, sudden onset of fever, nausea, abdominal pain, and jaundice after a few days. The illness can range from mild to severe lasting from one to two weeks or for several months. Severe cases can be fatal especially in older persons. Most infections are asymptomatic in children under six years of age, but infants and children can continue to shed the virus for up to six months after being infected, spreading the infection to others. Many countries are now including vaccination against Hepatitis A in their childhood vaccination schedules.

Prevention: Practice good personal hygiene, including washing your hands frequently and thoroughly, drink boiled or bottled water, eat well cooked foods, and peel your own fruits.

Vaccination: Recommended for all travellers over 1 year of age.
There are two inactivated vaccines available in Canada and the USA, including a combined Hepatitis A and Hepatitis B vaccine. A combined Hepatitis A and Typhoid Fever vaccine is also available in Canada and Europe. Hepatitis A vaccines confer long term protection and can be given in accelerated schedules. Discuss your options with your healthcare provider if you cannot finish the series prior to your departure. Immune Globulin may be recommended for some last-minute travellers.

Typhoid Fever

Typhoid Fever is a gastro-intestinal infection caused by Salmonella enterica typhi bacteria. It is transmitted from person to person – humans being the only reservoir – via the fecal-oral route where an infected or asymptomatic individual (does not exhibit symptoms) with poor hand or body hygiene passes the infection to another person when handling food and water. The bacteria multiply in the intestinal tract and can spread to the bloodstream. Paratyphoid fever, a similar illness, is caused by Salmonella enterica paratyphi A, B, and C.

Risk: The infection is endemic in many Southeast Asian countries as well as in Central and South America, the Caribbean, and Africa where there is poor water and sewage sanitation. Floods in these regions can also quickly spread the bacteria. All travellers going to endemic areas are at risk, especially long term travellers, adventure travellers, and those visiting friends or relatives in areas of poor sanitation. Note that original infection does not provide immunity to subsequent infections.

Symptoms:
Usually appear 1 to 3 weeks after exposure. Depending on the virulence of the infection symptoms can range from mild to severe. The illness is characterized by extreme fatigue and increasing fever. Other symptoms include headache, lack of appetite, malaise, and an enlarged liver. Sometimes patients have diarrhea, constipation, or a rash on their trunk. Severe symptoms may appear 2 to 3 weeks after onset illness and may include intestinal hemorrhage or perforation. Some people who recover from Typhoid or Paratyphoid Fever continue to be carriers of the bacteria and can potentially infect others. Treatment includes antibiotics and supportive care of symptoms. Unfortunately, S. typhii resistance to antibiotics is increasing worldwide.

Prevention: Wash your hands frequently and thoroughly, and practice proper body hygiene. Drink purified water (boiled or untampered bottled water) and only eat well cooked foods. Use the mantra Boil it, Cook it, Peel it, or Forget it!

Vaccination: Recommended for travellers going to endemic areas.
There are two types of vaccines available; the inactivated injectable vaccine (lasting 2-3 years) and the live attenuated oral vaccine (lasting 5-7 years). Discuss your best options with your healthcare provider, including revaccination recommendations which differ in the USA and Canada. A combined Hepatitis A and Typhoid Fever vaccine is also available in Canada and Europe. Although typhoid vaccines do not provide 100% protection, they will reduce the severity of the illness. There is no vaccine available against Paratyphoid Fever.

Yellow Fever

Yellow Fever is a viral infection caused by RNA viruses belonging to the Flavivirus genus. It is a zoonosis (an animal disease that can spread to humans) primarily transmitted by daytime biting Aedes Aegypti female mosquitoes, but also by mosquitoes belonging to the Haemagogus genus.

In the sylvatic cycle, Yellow Fever is transmitted by mosquitoes that bite infected monkeys passing the infection to humans living in or visiting jungle areas. Yellow Fever is endemic in the sylvatic setting in sub-Saharan Africa and the tropical regions of South America. In the intermediate or savannah cycle, the infection is transmitted to humans via mosquitoes that bite infected monkeys or other humans living or working in jungle border areas in Africa. In the urban cycle, infected mosquitoes transmit Yellow Fever from person to person that can cause large outbreaks in cities and suburbs. Yellow Fever outbreaks occur periodically in Africa and have occurred sporadically in South America.

Risk: Travellers are at risk when going to endemic areas of Africa and South America.

Symptoms: Most infections are asymptomatic (persons do not exhibit symptoms). However, those who show symptoms get ill 3 to 6 days after being infected and have flu-like symptoms including sudden fever, headache, muscle pain, backache, nausea, and vomiting. Most people will recover from this illness but about 15% will develop severe symptoms within 48 hours, including vomiting, jaundice, bleeding, shock, and multiple organ failure. Treatment includes supportive care of symptoms, but the use of aspirin and non-steroidal anti-inflammatory medications must be avoided since it increases the risk of bleeding.

Prevention: Yellow Fever is a vaccine preventable disease. Vaccination is recommended for persons over 9 months of age travelling to or living in endemic areas. The vaccine affords long term protection.

If going to low risk Yellow Fever areas, travellers should also take measures to prevent mosquito bites both indoors and outdoors, especially during the daytime. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray (or solution) to clothing and gear, wearing long sleeves and pants, getting rid of water containers around dwellings and ensuring that door and window screens work properly.

Vaccination precautions: Children between the ages of 6 to 8 months, persons over 60 years, those with asymptomatic HIV, pregnant, or breastfeeding. Vaccination should only be given if travel to endemic area cannot be delayed or avoided.

Vaccination contraindications: Children under 6 months of age, persons with immune deficiencies or on immunosuppressive therapies, allergies to egg proteins, transplant recipients, and persons with symptomatic HIV infection.

For your protection, Yellow Fever vaccination is recommended for all travellers over 9 months of age travelling at altitudes below 2300m / 7546ft in all regions of the Amazon Basin (east of the Andes mountains), including the following regions west of the Andes: Anash, Apurimac, Ayacucho, Cajamarca, Cuzco, Huancavelica, Huanuco, Junin, La Libertad, Pasco, Piura, and Puno.

Vaccination is not recommended if only travelling to the provinces of Lambayeque
, Tumbes, western Piura, and northwestern Cajamarca. Take meticulous anti-mosquito bite measures during the daytime in these areas.

Machu Picchu, the Inca Trail, the cities of Lima and Cuzco, and the regions of Arequipa, Callao, Ica, Lima, Moquegua, and Tacna are risk free.

Selective Vaccinations

Hepatitis B

The Hepatitis B virus (HBV) can cause acute and chronic liver infections. It is transmitted through infected blood products, unprotected sex, infected items such as needles, razor blades, dental or medical equipment, unscreened blood transfusions, or from mother to child at birth. The virus is present worldwide, but some populations in sub-Saharan Africa, Southeast Asia, Eastern Europe, and the Middle East, as well as indigenous communities are chronic Hepatitis B carriers.

Risk: Travellers getting tattoos or piercing abroad, using drugs intravenously, sharing needles and razor blades, undergoing dental or medical procedures, or having unprotected sex are at risk.

Symptoms:
In many cases, the infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms will usually get ill between 30 days and 6 months after becoming infected. Symptoms include fatigue, malaise, nausea, abdominal pain, dark urine, and jaundice. The illness can last several weeks and some adults can become chronic carriers after being infected. Hepatitis B can cause chronic liver infections, cirrhosis of the liver, or liver cancer. Most infections are asymptomatic in children under five years of age but they can become chronic carriers. Many countries are now including vaccination against Hepatitis B in their childhood vaccination schedules. Treatment includes supportive care of symptoms. Some cases of chronic Hepatitis B can be treated with antiretroviral drugs.

Prevention: Avoid getting new piercings or tattoos on your trip and do not share needles or razor blades. If you need medical or dental care abroad, ensure that it is done by a reputable provider. Always practice safe sex.

Vaccination: Hepatitis B vaccination is a routine immunization. If you haven’t been vaccinated, it is recommended for travellers on working assignments in the health care field such as physicians, nurses, laboratory technicians, dentists, or for those working in close contact with the local population such as teachers, aid workers, and missionaries.

There are two inactivated vaccines available in the Canada and the USA, including a combined Hepatitis A and Hepatitis B vaccine. Both types of vaccines confer long term protection and can be given in accelerated schedules. Discuss your options with your healthcare provider if you cannot finish the series prior to your departure.

Rabies

Rabies is a viral infection caused by viruses belonging to the Lyssavirus genus. It is a zoonosis (an animal disease that can spread to humans) transmitted through the saliva of infected mammals bites. The infection primarily circulates among domestic and wild animals such as dogs, cats, monkeys, foxes, bats, raccoons, and skunks, although all mammals are at risk. The virus attacks the Central Nervous System targeting the brain and the spinal cord, and if untreated is fatal.

Risk: Rabies is present on all continents except Antarctica. The majority of human infections occur in Asia and Africa. Travellers coming into close contact with domestic animals or wildlife on ecotourism trips, or those undertaking outdoor activities like cave exploring, camping, trekking, and visiting farms or rural areas are at higher risk. Rabies is also an occupational hazard for veterinarians and wildlife researchers. Children are especially vulnerable since they may not report scratches or bites. They should be cautioned not to pet dogs, cats, monkeys, or other mammals. Any animal bite or scratch must be washed repeatedly with copious amounts of soap and water. Seek medical attention immediately.

Symptoms: Usually appear 1 to 3 months or later, although they can appear as early as a few days after being infected. The illness is characterized by fever and pain or a tingling sensation at the wound site. As a result of inflammation to the brain and spinal cord, some patients present with anxiety, hyperactivity, convulsions, delirium, and have a fear of swallowing or drinking liquids, as well as a fear of moving air or drafts. In other patients, muscles become paralysed followed by a coma. Once symptoms are present, most patients die within 1 or 2 weeks.

Prevention: Avoid contact with feral animals or wildlife. Try to anticipate an animal’s actions and always be careful not to make sudden moves or surprise them. If you’ve been bitten by a mammal, wash the wound repeatedly and thoroughly with soap and water. Seek medical attention immediately.

Vaccination: A series of 3 pre-exposure rabies vaccination shots is advised for persons planning an extended stay or on working assignments in remote and rural areas, particularly in Africa, Asia, Central and South America. The pre-exposure series simplifies medical care if you have been bitten by a rabid animal and gives you enough time to travel back from a remote area to seek medical attention. Although this provides adequate initial protection, you will require 2 additional post-exposure doses if you are exposed to rabies. The preferred vaccines for rabies pre-exposure vaccination and post-exposure therapy are HDCV (Human Diploid Cell Rabies vaccine) and PCEC (Purified Chick Embryo Cell vaccine). These two vaccines are interchangeable.

Travellers who have not received the pre-exposure shots need 4 injections (those with compromised immune systems need 5 injections) and the Human Rabies Immune Globulin (HRIG) which is calculated as 20 IU (International Units) per kilo of body weight. HRIG must be injected around the bite site and intramuscularly. In some countries purified Equine Rabies Immune Globulin (ERIG) is used for post-exposure therapy when HRIG is not available. HRIG is in short supply worldwide and is often not available in rural and remote areas.

Note: If you are in a remote area and offered daily rabies injections lasting 14 to 21 days, it may be one of the older animal brain-derived vaccines. We recommend that you do not take them due to serious side effects.

The recommendations for vaccinations outlined above are intended as guidelines only. Your immunization needs depend on your health status, previous immunizations received, and your travel itinerary. Seek further advice from your doctor or travel health clinic.

Health Risks

MALARIA

Infection is spread by the night-time - dusk to dawn - biting female Anopheles mosquito.

Malaria risk is present throughout the country, including urban areas, except areas specified:

Risk is present in all regions (cities and rural areas below 2000m / 6561ft) except in the city of Lima and the coastal area south of Lima, the city of Ica, and the southern regions of Arequipa, Moquegua, Tacna, and the city of Puno.

Note: Persons visiting the high altitude areas of Cuzco, Machu Picchu, and Lake Titicaca are not at risk.

Malaria risk is present below the altitude of: 2500 meters

High risk months for Malaria are: January - December

Malaria transmission vector(s): A. albimanus, A. darlingi, A. pseudopunctipennis pseudopunctipennis
(see Anopheles code chart)

Incidence of Plasmodium falciparum Malaria: 11%
Of the five species of human malaria parasites, Plasmodium falciparum is the most dangerous. The remaining percentage represents malaria infections that may be caused by one or more of the following parasites: Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi.

Areas with drug resistant Malaria: Multi-drug resistant (chloroquine and sulfadoxine-pyrimethamine) P. falciparum malaria is present in all malarious areas of Peru. Chloroquine resistant P. vivax malaria has also been reported from this country.

Suppressive Medication Guide: Anti-malarial advice for this country

For details on anti-malarial drug side-effects, dosages for children and pregnant women, medications used around the world, and comprehensive protection measures, see: How to Protect Yourself Against Malaria (pdf)

MALARIA RISK WORLD MAP

CHAGAS' DISEASE

Infection is spread by the Triatoma insect in rural and suburban areas of Mexico, Central America, and South America.

Risk is present in two separate geographical areas:
1) Rural and suburban areas of departments in the northern part of the country bordering Ecuador: Tumbes, Piura, Cajamarca, Amazona, and Loreto (foci in eastern Loreto in the areas of Javary and Amazon rivers bordering Brazil).

Main vector: Triatoma dimidiata.

2) In the southern half of Peru in areas below 3500m, particularly in the rural and suburban areas of the follwoing coastal departments: Arequipa, Ica, Moquegua, Tacna.

Main vector: Triatoma infestans. The insect is locally known as 'vinchuca' or 'chirimacha'.

Prevention Guidelines: Rules for preventing Chagas' Disease

CHAGAS' DISEASE RISK WORLD MAP

OTHER HEALTH RISKS OF INTEREST TO TRAVELLERS

The health risks listed below are some of the most common non-vaccine preventable illnesses that can affect travellers. We update our travel health information daily with any new confirmed outbreaks so check back here before your trip for updates. Please note that some infectious diseases are not reported or under reported, preventing us from giving you the full picture of the health risk.

Air Pollution

Outdoor air pollution (a mix of chemicals, particulate matter, and biological materials that react with each other) contributes to breathing problems, chronic diseases, increased hospitalization, and premature mortality.

Risk: No matter where you travel, you will not be able to escape air pollution since cities and rural areas worldwide are affected by air pollution. Exposure and concentration of pollutants can adversely affect your health. When planning your trip, consider your health status, age, destination, length of trip and season to help you mitigate the effects of air pollution.

Symptoms: Short term symptoms resulting from exposure to air pollution include itchy eyes, nose and throat, wheezing, coughing, shortness of breath, chest pain, headaches, nausea, and upper respiratory infections (bronchitis and pneumonia). It also exacerbates asthma and emphysema. Long term effects include lung cancer, cardiovascular disease, chronic respiratory illness, and developing allergies. Air pollution is also associated with heart attacks and strokes.

Prevention:
Comply with air pollution advisories (ask around and observe what locals are doing) and avoid strenuous activity. If you have asthma or chronic obstructive pulmonary disease (COPD), carry an inhaler, antibiotic, and oral steroid (consult your doctor to see what is best for you). It is recommended that older travellers get a physical exam that includes a stress and lung capacity test prior to departure. Newborns and young children should minimize exposure as much as possible or consider not travelling to areas with poor air quality. Ask your medical practitioner if a face mask is advisable for you.

>> For city and country air pollution levels, see the
World Health Organization.

Peru reports high concentrations of particulate matter (PM10 - particles with an aerodynamic diameter smaller than 10 µm) contributing to low air quality.

Altitude Illness

Altitude Illnesss occurs as a result of decreased oxygen pressure at high altitudes. The illness is divided into three syndromes recognized by a cluster of symptoms arising from rapid ascent to high altitudes, especially more than 2400m / 7874ft.

Risk: All non-acclimatized travellers, including children, are potentially at risk of developing altitude illness which depends on level of exertion, speed of ascent, altitude reached, humidity, oxygen, and air pressure levels, as well as personal susceptibility. The human body is able to acclimatize to high altitude but must be given time to do so, ideally 3 to 5 days.

Symptoms: The first syndrome, Acute Mountain Sickness (AMS), is characterized by headache, fatigue, loss of appetite, nausea and sometimes vomiting, dizziness, insomnia and disturbed sleep appearing 2 to 12 hours after arrival at high altitude. Symptoms usually disappear within 24 to 72 hours as the body acclimatizes to the altitude. If AMS symptoms persist, rest and medication is needed. Do not continue to ascend to a higher altitude if symptoms persist. If there is no improvement descend to a lower altitude, by at least 300m / 984ft.

In rare cases AMS progresses to the second syndrome, High Altitude Cerebral Edema (HACE), which is characterized by worsening AMS symptoms, drowsiness, confusion, staggering gate and ataxia (lack of voluntary muscle coordination). Immediate descent to lower altitude is important since developing HACE symptoms can be life threatening if untreated immediately. HACE is rare at altitudes below 3600m / 11811ft.

The third syndrome, High Altitude Pulmonary Edema (HAPE), affects the lungs and is characterized by increased breathlessness with exertion progressing to breathlessness during rest, a dry cough, chest tightness or congestion, rapid heart beat, general weakness, and blue / purple skin tissue coloration. Developing HAPE symptoms can be life threatening if untreated. Immediate descent to a lower altitude and administration of oxygen are imperative.

Descending immediately, combined with medication (and oxygen, if available), is the best treatment for severe AMS, HACE, or HAPE. Consider evacuation if necessary.

Acclimatizing to high altitudes:

  • Your ascent schedule should include rest days and flexibility in case you need to slow down and adjust to the new altitude. A gradual ascent to high altitude, possibly over a few days, is ideal. If this is not possible, make sure to allow extra time to acclimatize: 1 day for every 1000m / 3280ft.
  • Avoid strenuous exercise for the first two days and avoid all alcoholic beverages for the first few days.
  • Set a reasonable pace, avoid over exertion, and keep hydrated. Do not overload yourself with extra gear. If you are camping at high altitudes, ensure that there is good ventilation when using camp stoves and heaters in confined spaces.
  • Consult with your healthcare provider if taking acetazolamide (Diamox) or other medication to help with acclimatization is appropriate for you.
  • Persons with chronic medical conditions such as angina, heart failure, pulmonary diseases, and diabetes should consult with a high altitude medicine specialist before going travelling to mountainous areas.

Prevention: Plan your ascent over several days to ensure proper acclimatization (at altitudes of more than 2400m / 7874ft, ascend at a rate of no more than 300m / 984ft per day). Learn about the symptoms before you go and heed the warnings when symptoms appear. Do not continue to higher altitude, especially to sleep, when symptoms appear even if you feel they are minor. Descend to a lower altitude (at least 300m / 984ft) if symptoms persist while resting at your current altitude.

Risk of altitude illness is present in the Sierra region of central Peru which contains the Andes mountain ranges (elevations from 2743m to 5791m / 8999ft to 18999ft). The city of Cuzco is at 3500m / 9800ft. Travellers arriving there should spend several days acclimatizing and avoiding strenuous activity.

Chikungunya

Chikungunya is a viral infection transmitted to humans through the bite of infected daytime biting female mosquitos. The Aëdes aegypti mosquito is the primary vector, but the Aëdes albopictus mosquito is also responsible for transmitting the CHIK virus belonging to the Togaviridae family.

Risk: Travellers going to parts of the Caribbean, sub-Saharan Africa, southeast Asia, and the Indian subcontinent are at risk, especially during the rainy season. The mosquitos usually bite early morning and late afternoon and are typically found in and around domestic dwellings. Some mosquitos carrying the Chikungunya virus in Africa also live in forested areas. Monkeys and other wild animals are also believed to be reservoirs for the virus. Isolated cases of imported Chikungunya have occurred in the Americas and Europe.

Symptoms: The initial symptoms of sudden fever and sever muscle and joint pain usually appear between 3 to 7 days and sometimes until 12 days after the bite. Not everyone exhibits symptoms and the infection may go undetected. Other symptoms include headache, fatigue nausea, vomiting, and a rash. Although most patients fully recover, chronic joint pain may last for several weeks or months. Other persistent problems may include eye, gastrointestinal, neurological, and heart complications. Sometimes Chikungunya is misdiagnosed in areas where Dengue also occurs.

Persons with chronic health conditions, compromised immune systems, newborns, the elderly are at risk of developing complications with this infection. Chikungunya is rarely fatal.

Prevention: Travellers should take measures to prevent mosquito bites both indoors and outdoors, especially during the daytime. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray (or solution) to clothing and gear, wearing long sleeves and pants, getting rid of water containers around dwellings and ensuring that door and window screens work properly. There is no preventive vaccine against Chikungunya.

Peru has reported cases of Chikungunya fever. For the latest information on Chikungunya fever outbreaks please go to: ProMED-mail. Chikungunya (46): Caribbean. ProMED-mail 2014; August 15: 20140815.2694023. <www.promedmail.org>. Accessed on August 18, 2014.

Dengue

Dengue is a viral infection caused by five types of viruses (DENV) belonging to the Flavivirdae family. The viruses are transmitted through the bite of infected Aëdes aegypti and Aëdes albopictus female mosquitoes that feed both indoors and outdoors during the daytime (from dawn to dusk). In 2013, scientists confirmed the existence of a fifth Dengue virus serotype which could pose a further challenge to developing a vaccine against the infection in humans.

Risk: The viruses are present in tropical and subtropical areas of Central America, South America, Africa, Asia, and Oceania. All travellers are at risk during epidemics. Long-term travellers and aid or missionary workers going to areas where Dengue is endemic are at higher risk. Dengue occurs in urban and suburban settings with higher transmission rates happening during the rainy season.

Symptoms: In some cases, Dengue infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms get ill between 4 to 7 days after the bite. The infection is characterized by flu-like symptoms which include a sudden high fever coming in separate waves, pain behind the eyes, muscle, joint, and bone pain, severe headache, and a skin rash characterized by bright red spots.

The illness may progress to Dengue Hemorrhagic Fever (DHF). Symptoms include severe abdominal pain, vomiting, diarrhea, convulsions, bruising, and uncontrolled bleeding. High fever can last from 2 to 7 days. Complications can lead to circulatory system failure and shock, and can be fatal. Exposure to one type of Dengue virus does not provide immunity to the other three types. Contracting Dengue more than once increases the risk of developing Dengue Hemorrhagic Fever.

Prevention: Travellers should take measures to prevent mosquito bites during the daytime. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray (or solution) to clothing and gear, wearing long sleeves and pants, getting rid of water containers around dwellings and ensuring that door and window screens work properly. There is currently no preventive medication or vaccine against Dengue.

>> For Dengue images, life cycle, and distribution maps, see Infection Landscapes.

Country at risk for dengue fever transmission.

Peru has reported Dengue fever cases nationally. Departments most affected include: Piura, Tumbes, Loreto, San Martin, Madre de Dios, Ucayali, Junin, Cajamarca, Cusco, Amazonas, Huanuco and La Libertad. For the latest information on Dengue fever outbreaks please go to: ProMED-mail. Dengue/DHF Update (51): Americas, Asia, Europe. ProMED-mail 2014; August 27: 20140827.2727801. <www.promedmail.org>. Accessed on August 28, 2014.

Intestinal Parasites | Soil-Transmitted Helminths

Parasitic worms are organisms that can live and replicate in the gastro-intestinal system. These soil-transmitted helminths (hookworms, roundworms, whipworms) are transmitted through the fecal-oral route as a result of poor sanitary practices. The most common infections that can affect travellers are Ascariasis, Hookworm, and Trichuriasis which are Neglected Tropical Diseases (NTDs)*.

Risk: Travellers can get ill when worm eggs are ingested by:

  • Eating raw, unwashed, or improperly handled fruits and vegetables.
  • Drinking contaminated water or beverages.
  • Touching the mouth with dirty hands or through improper hand washing.
  • Practising poor body hygiene.

Ascariasis: The infection is caused by Ascaris lumbricoides roundworm and is typically found in tropical and sub-tropical areas. Persons with light infections may not exhibit any symptoms. Those who develop symptoms start with a persistent cough, wheezing, shortness within 1 week of getting infected as a result of larvae migrating to the lungs and throat. The second set of symptoms, including abdominal pain, nausea, vomiting, diarrhea, bloody or worm in stools, fatigue, weight loss appear a few weeks (up to 2 or 3 months) later as the roundworms become adults and the females lay eggs which are shed through feces. The parasite can live in humans for up to 2 years. Children are particularly affected by this illness because they tend to play in and eat dirt. Treatment includes taking anthelmintic drugs.  

Hookworm | Ancyclostomiasis: This intestinal infection is primarily caused by Necator americanus, followed by Ancylostoma duodenale, and to a lesser extent by Ancylostoma ceylanicum nematodes typically found in tropical and sub-tropical areas. Persons with light infections may not exhibit any symptoms. Those who develop symptoms first get a skin rash where the larvae penetrate the skin. Abdominal pain, diarrhea, loss of appetite, weight loss, and fatigue occur as the migrated larvae grow into adults and mate in the gastro-intestinal system. The eggs produced by the females are shed through feces. Note that the Ancylostoma duodenale hookworm can also be acquired by ingesting soil or sand through dirty hands or unwashed fruits and vegetables.A typical sign of this infection is anemia (iron deficiency). Treatment includes taking anthelmintic drugs.

Trichuriasis: The infection in humans is caused by the Trichuris trichuria whipworm and occurs worldwide, especially in areas with no proper sewage disposal. Persons with light infections may not exhibit any symptoms. Those who exhibit symptoms have diarrhea, containing blood, mucous, and water as a result of the swallowed eggs hatching in the caecum, the pouch-like area of the large intestine, and the larvae migrate to the lining the colon to grow into adulthood and mate. The eggs produced by the females are shed through feces. Severe cases include abdominal pain, chronic diarrhea, and rectal prolapse. Whipworms can live in humans for years. Children are particularly affected by this illness because they tend to play in and eat dirt. Treatment includes taking anthelmintic drugs.

* Neglected Tropical Diseases are chronic infections that are typically endemic in low income countries. They prevent affected adults and children from going to school, working, or fully participating in community life, contributing to stigma and the cycle of poverty.

Risk exists in Peru.

Leishmaniasis

Leishmaniasis is a parasitic infection caused by different species of Leishmania protozoa. It is transmitted through the bite of infected female sandflies belonging to the Phlebotomus, Lutzomyia, and Psychodopygus species. These insects can bite at any time of the day, but are most active from dusk to dawn and are often found in forests, stone and mud walls cracks, and animal burrows. They are very tiny silent flyers – they do not hum – and their bite might go unnoticed. Leishmaniasis is clinically divided into three major categories – cutaneous, mucocutaneous, and visceral – and is a Neglected Tropical Disease (NTD)*.

Risk: Adventure travellers, bird watchers, missionaries, army personnel, construction workers, and researchers on night time assignments are at higher risk of being exposed to sand flies.

Cutaneous Leishmaniasis
is the most common form of the infection and is found in two geographic areas:

  • Old World Cutaneous Leishmaniasis is present in the Mediterranean basin (southern Europe and North Africa), the Middle East, southwest and central Asia, and the tropical areas of Africa. The majority of cases are reported from the following countries: Afghanistan, Algeria, Iran, Iraq, Saudi Arabia and Syria. Old World cutaneous leishmaniasis is a mostly self-limiting skin disease in adults, but depending on the species, infected infants and children can develop the visceral form of the disease.
  • New World Cutaneous Leishmaniasis is common in rural areas but can also be acquired in semi-urban and urban areas. It also occurs in rainforests and arid areas. New World cutaneous leishmaniasis is present in parts of North America (occasional cases are reported from the states of Texas and Oklahoma), Mexico, Central and South America, with Brazil and Peru reporting the majority of cases.

Symptoms of Cutaneous Leishmaniasis: Initial symptoms include skin lesions, which develop after several weeks or months after being infected, and swollen glands. The lesions - closed or open sores - can change overtime in size and appearance, they are usually painless, but can become painful if infected with bacteria. The lesions can take a long time to heal and usually leave scarring. Infections with some strains of New World cutaneous leishmaniasis may develop into Mucocutaneous Leishmaniasis years after the initial skin lesions seem to have healed completely. The infection spreads to the nose, mouth, and throat causing sores and bleeding. This complication can occur when the initial cutaneous leishmaniasis has not been treated.

Visceral Leishmaniasis, also know as kala-azar, is caused by some Leishmania species that invade the liver, spleen, bone marrow, and skin.

Symptoms of Visceral Leishmaniasis: Usually appear weeks or months after being infected and include fever, weight loss, and enlarged liver. Advanced untreated visceral leishmaniasis can be fatal, particularly if other underlying medical conditions such as tuberculosis, pneumonia, and dysentry are present. This form of Leishmaniasis is very rare in travellers but it affects local populations in remote areas of India, Nepal, Bangladesh, Sudan, South Sudan, Ethiopia, and Brazil.

Prevention: Avoid any activity that may disturb sandfly habitats, especially from dusk to dawn. Presoak protective clothing with permethrin insecticide. Use insect repellent containing DEET on exposed skin and sleep under permethrin treated bed nets or in air conditioned areas. (Sand flies are very small, 2-3 mm, and may be able to enter through regular screens and nettings. Insecticide treated screens and nets can reduce risk of entry). There is no preventive vaccination or medication against Leishmaniasis. Treatment options depend on identifying the infective leishmania species and the extent of the infection, but generally includes antifungal and antibacterial ointments.

* Neglected Tropical Diseases are chronic infections that are typically endemic in low income countries. They prevent affected adults and children from going to school, working, or fully participating in community life, contributing to stigma and the cycle of poverty.

>> For Leishmaniasis images, life cycle, and distribution maps, see Infection Landscapes.

Leishmaniasis is endemic in Peru. Cutaneous leishmaniasis is endemic in Andean and inter-Andean valleys and foothills of Peru between the northern border of the country to the level of Cuzco (to the south) within an altitude range up to 3000m / 9842ft above sea level. Mucosal leishmaniasis is endemic in the tropical rainforests at lower altitudes. Visceral leishmaniasis does not occur.

Sexually Transmitted Infections

Sexually transmitted infections (STIs), also known as Sexually Transmitted Diseases (STDs), are caused by bacteria, viruses or parasites and are transmitted via unprotected sex (oral, anal, or oral) and skin to skin genital contact.

Bacterial infections include Bacterial Vaginosis, Chlamydia, Gonorrhea, Lyphogranuloma venerum (LGV) and Syphilis. Viruses cause Genital Herpes, Hepatitis B, Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV). Parasites are responsible for Trichomoniasis and pubic lice.

STIs occur worldwide, but some infections like chancroid, lymphogranuloma vernerum (LGV), and Granuloma Inguinale are more common in less industrialized countries.

Risk: Travellers are at high risk of acquiring STIs if they have unprotected sex outside a monogamous relationship, engage in casual sex, or use the services of sex workers. During travel, some people may be less inclined to follow social mores dictating their behaviour back home and look for adventurous opportunities involving sex. Long term travellers may also be at increased risk due to feelings of loneliness or being homesick.

Travellers should also be aware of sexual tourismand how it spreads STIs. Sexual tourism is travel for the procurement of sex abroad. Travellers participating in this type of exploitive tourism use the services of sex workers or children that are forced to engage in the trade as a result of deceptive practices or are part of human trafficking networks. It’s illegal in many countries and you can be prosecuted in your home country for engaging in sexual exploitation of minors abroad. Sexual violence such as rape or assault can also increase risk of STI.

Symptoms: In many cases you can spread a sexually transmitted infection unknowingly because you are asymptomatic (do not exhibit symptoms). Depending on the infection, symptoms can appear within days or weeks (Chlamydia, Gonorrhea, Genital Herpes), weeks or months (Hepatitis B, Syphilis, HIV) after the initial infection. Common symptoms, which may appear alone or in combination include abnormal genital discharge, burning sensation when urinating, bleeding after intercourse or between periods, rashes and sores in the genital or anal areas, swollen lymph glands in the groin, and sudden fever or appearance of flu-like symptoms.

Note that the sudden or eventual disappearance of symptoms does not mean you are cured from the infection since it can return or manifest itself in different symptoms. Many sexually transmitted infections can be treated with antibiotics (although there is mounting evidence that Gonorrhea is becoming increasingly resistant to antibiotics) or antivirals. If left untreated, infections can lead to infertility, pelvic inflammatory disease, cancer, chronic liver conditions, pregnancy complications, and birth defects.

Prevention: Always practice safe sex. Pack your own male and / or female condoms. Note that condoms obtained abroad may have higher breakage rates, may be expired, or may have been stored in hot or humid places compromising their effectiveness. Use your condom correctly and do not use oil based lubes. If you engage in oral sex use a male condom or dental dam. Keep in mind that birth control methods such as oral contraceptives, injections, IUDs, or diaphragms do not prevent STI transmission, and that condoms aren’t fully effective from infections acquired via skin-to-skin contact like genital herpes.

Avoid behaviour that increases your chances of contracting an STI such as casual sex with a stranger or a sex worker. Drinking heavily or taking mind-altering drugs will impair your judgement and inhibitions during a sexual encounter, putting you at risk of making unsafe choices like not using a condom. If you already practice safe sex, avoid getting tattoos, body piercings, or acupuncture treatments. Also don’t share razors, toothbrushes, or needles. If you have engaged in risky sexual activities or suspect that you may have an STI, visit a healthcare provider immediately. If the results confirm that you have an STI, inform all your sex partners and encourage them to seek medical attention.

Hepatitis B and Human Papillomavirus (HPV) can also be prevented through vaccination.

Note: Some countries continue to have entry restrictions for travellers with HIV / AIDS. Consult your destination country's embassy or consulate to get the latest information. See also HIVTravel for details.

Traveller's Diarrhea

The term Traveller's Diarrhea is used to describe gastro-intestinal infections affecting travellers caused by ingesting bacteria, viruses, and protozoa. These micro-organisms are found worldwide and are typically transmitted from person to person via the fecal-oral route – an infected person who does not practice proper hand or body hygiene passes on the infection to another person when handling food and water. Traveller's Diarrhea is the most common illness among travellers.

Risk:
Traveller’s Diarrhea can happen when:

  • Eating raw, under cooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood.
  • Drinking contaminated water or beverages.
  • Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
  • Eating out in restaurants, from buffets, or from street vendors where food handling and hygienic practices are not followed properly.

Prevention: The golden rule to prevent gastro-intestinal infections is: Boil it, Cook it, Peel it, or Forget it! However, it’s not just about what you eat, it’s also important to consider where you eat. It’s not always easy to know if a restaurant or food vendor follows proper food handling and hygienic practices (properly cleaning cutting boards, utensils, sink to wash hands, refrigeration). Be cautious of food that has been stored uncovered, has been improperly refrigerated, or has been standing out for a long time such as buffets.

Consult your doctor for the best treatment options tailored to your needs, including taking prescription medication on your trip in case you suffer from diarrhea. Travellers with chronic conditions are more susceptible to infections and should consider taking preventive medication.


More information on Food and Water Safety:
>> How To Prevent Traveller's Diarrhea [PDF]
>> How To Prevent Food and Water Illnesses [PDF]
>> How To Prevent Illness by Washing Your Hands [PDF]
>> 24 World Food and Climate Charts

>> Guide to Healthy Travel

HEALTH RISKS FOR SPECIFIC TRAVELLERS

The health risks listed below are of interest to travellers who undertake special activities like adventure travel or ecotourism, long term travellers, visiting friends and family, or those on work assignments abroad. We update our travel health information daily with any new confirmed outbreaks so check back here before your trip for updates. Please note that some infectious diseases are not reported or under reported, preventing us from giving you the full picture of the health risk.

Anthrax

Anthrax is a zoonosis (an animal disease that can spread to humans) caused by the bacteria Bacillus anthracis. Spores can lie dormant for long periods of time, usually in soil, until it becomes an infectious agent. It's a common disease in livestock such as cattle, sheep, goats, and camels.

Risk:
Anthrax is present worldwide, but outbreaks typically occur in tropical and subtropical regions. Travellers are at risk when coming into contact with infected animals or infected animal products such as contaminated wools and hides. The bacteria germinates during the dry season and can also be present during the wet season.

Symptoms: Usually appear within 7 days of exposure. It can be contracted through:

  1. Skin lesions where the bacteria invade the blood stream and cause a blister, sore or skin ulcer characterized by dying skin (black area) in the center.
  2. Ingestion by eating undercooked meat of infected animals causing nausea, fever, stomach pain, bloody diarrhea, vomiting blood, and loss of appetite.
  3. Inhalation where a person develops flu like symptoms which may lead to a sore throat, fever, and muscle aches. More severe symptoms include a cough, shortness of breath, fatigue, and may progress to shock which can be fatal.

Seek medical attention immediately if you suspect exposure to Anthrax. Treatment includes antibiotics.

Prevention: Ensure that meats are well cooked or cured. Do not buy souvenirs or clothing made from animal hides or wool. A vaccine against anthrax is available although it is only given to high risk groups such as military personnel, veterinarians who work abroad, people working in the animal hide and fur sector, and lab workers handling the bacteria.

Anthrax is endemic in Peru and has long been a problem, mainly in the coastal provinces such as Callao, Lambayeque, Moquegua, Tumbes, La Libertad, Ancash, Lima, Ica and Cajamarca, Huanuco, and Cerro de Pasco.

Plague

Plague is a zoonosis (an animal disease that can spread to humans) caused by Yersinia pestis bacteria. It is transmitted to humans from rodents such as squirrels, chipmunks, woodrats, prairie dogs, rabbits, and mice through the bite of an infected flea. There are three forms of the infection:

  1. Bubonic plague primarily affects the lymph nodes.
  2. Septicemic plague affects the bloodstream and can be contracted by handling infected animals.
  3. Pneumonic plague affects the lungs and can spread from person to person, though rarely, through contaminated air droplets.

Risk: Plague is primarily found in arid regions of Africa, South America, Asia, and North America. Hikers, campers, hunters, and persons occupationally exposed to wild rodents in endemic areas such as anthropologists, archeologists, geologists, spelunkers are at greater risk of exposure.

Symptoms: Flu-like symptoms appear 1 to 10 days after being bitten, including fever, headache, chills, muscle pain, weakness. The illness is also characterized by painful lymph glands. If untreated, the infection can spread to the bloodstream, also known as septicemic plague, which is accompanied by abdominal pain, shock, and internal bleeding of organs and skin tissue may turn black. Pneumonic plague can also develop if bubonic or septicemic plague is untreated. In this case, the patient has shortness of breath chest pain, and may cough blood or watery mucous. Shock and respiratory failure can become fatal. Rapid diagnosis and treatment with antibiotics is important for a full recovery. Patients need to be isolated to prevent possible spread of the infection to others.

Prevention: Ensure that your accommodations or camping area is free of rodents and remove any food sources or potential nesting materials. Avoid direct contact with rodents, carnivores who eat rodents, and dead animal tissues. Make sure cats and dogs around you do not carry fleas. There is currently no commercially available vaccine or preventive medication against Plague.

>> For Plague images, life cycle, and distribution maps, see  Infection Landscapes.

Risk is present in northern Peru in the Departments of Cajamarca (Chota, San Miguel, and San Pablo provinces), La Libertad, Lambayeque, Piura (Ayabaca, Huancabamba, Piura provinces), and Ancash (southern part).

Tuberculosis

Tuberculosis (TB) is an airbone bacterial infection caused by Mycobacterium tuberculosis. TB can be acquired by breathing contaminated air droplets coughed or sneezed by a person nearby who has active Tuberculosis. Humans can also get ill with TB by ingesting unpasteurized milk products contaminated with Mycobacterium bovis, also known as Bovine Tuberculosis. The most common form of the infection is pulmonary TB which affects the lungs. In some cases, the bacteria can also attack the lymphatic system, central nervous system, urogenital area, joints, and bones.

Risk: Tuberculosis occurs worldwide and commonly spreads in cramped, overcrowded conditions. There is no evidence that pulmonary TB is more easily transmitted in airplanes or other forms of public transportation. Travellers with a compromised immune system, long-term travellers, and those visiting friends and relatives (VFR travellers) in areas where Tuberculosis is endemic are at greater risk. Humanitarian and healthcare personnel working in communities with active TB are also at increased risk. Persons with active TB should not travel.

Symptoms: Persons with active TB have symptoms which include excessive coughing (sometimes with blood), chest pain, general weakness, lack of appetite, weight loss, swollen lymph glands, fever, chills, and night sweats. It can be misdiagnosed for bronchitis or pneumonia. If untreated, active TB can lead to fatalities.

The majority of persons with the illness (90% to 95%) have latent TB infection (LTBI) and do not exhibit any symptoms. The bacteria can remain inactive for many years and the chance of developing active TB diminishes over time.

Tuberculosis treatment involves taking antibiotics for a minimum of 6 months. Drug-resistant TB is a major concern as an increasing number of people are no longer able to be treated with previously effective drugs. Due to misuse of antibiotic therapies, patients can develop multi-drug resistant Tuberculosis (MDR TB). When a second line of antibiotics fail to cure the multi-drug resistant infection, it is known as extensively drug-resistant Tuberculosis (XDR TB).

 

Prevention: Avoid exposure to people known to who have active Tuberculosis and only consume pasteurized milk products. Travellers at higher risk should have a pre-departure tuberculin skin test (TST) and be re-tested upon their return home. Those at increased risk should also consult their healthcare provider to determine if the Bacillus Calmette-Guérin (BCG) vaccine is recommended.

 

Tuberculosis is highly endemic and a major public health problem in Peru.

Food and Water Safety

All local water should be considered contaminated. All tap water used for drinking, brushing teeth, and making ice cubes should be boiled (bringing water to a good rolling boil is sufficient). Good brands of bottled water are available; check cap seal and ensure that the bottle is uncapped in your presence.

Milk should be boiled before consumption because of possible improper refrigeration during distribution. Powdered and evaporated milk are available and safe. Butter should not be used as a table food. Cream, ice cream, and whipped cream should not be consumed. Cheese, unless cured, is best avoided. Yoghurt is safe only if it is known to be made from pasteurized milk.

All meat, poultry, and fish must be well cooked and served while hot. Pork is best avoided; vegetables should be well cooked and served hot. Salads are best avoided. Fruits with intact skins should be peeled by you just prior to consumption. Avoid raw and undercooked eggs, and dishes prepared with raw eggs (steak tartar, mayonnaise, and dressings). Avoid cold buffets, uncured cheeses, custards, and any frozen desserts.

First rate hotels and restaurants serve purified drinking water and reliable food. However, the hazard is left to your judgement.

Chemicals found in food and water

Globalized food production and shipping are making it harder for consumers to know if their food and water is safe. Travellers should be aware that food and water contamination not only occurs through improper food handling or poor hygiene practices. Air, soil, and water pollution resulting from heavy metals, dioxins, pesticides, agro-chemicals, and drugs given to food-production animals, occurs worldwide. IAMAT recommends eating locally sourced foods from reputable growers as much as possible. We will post any new information on outbreaks resulting from environmental contamination on this page. Don’t forget to consult our website before your trip!

Food allergies

Being prepared is important to preventing allergic reactions or anaphylactic shock during your trip.

  • Research the common foods of your destination country and talk to your health practitioner about your travel plans.
  • Pack the medications you need to prevent an adverse reaction like antihistamines or epinephrine injectors with refills.
  • Find a reputable doctor or hospital prior to your trip in case of an emergency. Carry your IAMAT Traveller Clinical Record outlining your food allergies so that healthcare providers abroad are aware of your condition. 
  • If you’re grocery shopping abroad, read labels and be aware of packaging that does not list ingredients. Note that in many countries there are no or weak food labelling regulations and some products may be partially labelled.
  • Tell others about your food allergy. Carry a personalized translated card detailing your allergies to show restaurant waiters, grocery store clerks, or food vendors. SelectWisely offers a wide range of professionally translated cards.

Traveller’s Diarrhea

The term Traveller's Diarrhea is used to describe gastro-intestinal infections affecting travellers caused by ingesting bacteria, viruses, and protozoa. These micro-organisms are found worldwide and are typically transmitted from person to person via the fecal-oral route – an infected person who does not practice proper hand or body hygiene passes on the infection to another person when handling food and water. Traveller's Diarrhea is the most common illness among travellers.

Risk: Traveller’s Diarrhea can happen when:

  • Eating raw, undercooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood.
  • Drinking contaminated water or beverages.
  • Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
  • Eating out in restaurants, from buffets, or from street vendors where food handling and hygienic practices are not followed properly.

Prevention: The golden rule to prevent gastro-intestinal infections is: Boil it, Cook it, Peel it, or Forget it! However, it’s not just about what you eat, it’s also important to consider where you eat. It’s not always easy to know if a restaurant or food vendor follows proper food handling and hygienic practices (properly cleaning cutting boards, utensils, sink to wash hands, refrigeration). Be cautious of food that has been stored uncovered, has been improperly refrigerated, or has been standing out for a long time, such as buffets.

More information on Food and Water Safety:
>> How To Prevent Traveller's Diarrhea [PDF]
>> How To Prevent Food and Water Illnesses [PDF]
>> How To Prevent Illness by Washing Your Hands [PDF]
>> 24 World Food and Climate Charts

>> Guide to Healthy Travel

Bacteria
Approximately 85% of Traveller’s Diarrhea is caused by bacteria. Symptoms involving bacterial infections generally appear within hours of eating contaminated food or water and can last 3 to 7 days. Typical symptoms include diarrhea, abdominal pain, nausea, general weakness, headache, low fever, and possible vomiting. Severe cases can cause dehydration.

The following are common bacteria causing food and water illnesses in travellers:
Enterotoxigenic Escherichia coli (ETEC)
– Commonly known as ‘E. coli’ and responsible for the majority of Traveller’s Diarrhea cases. The illness is associated with contaminated food and water. Symptoms appear 1 to 3 days after infection. Treatment includes supportive care of symptoms and in severe cases antibiotics are prescribed.

Campylobacter jejuni– Associated with contaminated water, undercooked poultry, unpasteurized milk. Symptoms appear 1 to 7 days after being infected and can last 2 to 3 weeks without treatment. Some patients also have bloody diarrhea. Post-infection complications can lead to Guillain-Barré Syndrome, where the immune system attacks the nerves and causes paralysis, or irritable bowel syndrome. Treatment includes antibiotics.

Salmonella enteritidis
– Associated with eggs, poultry, meat, raw fruits and vegetables. Symptoms usually appear 1 to 3 days after infection and can last up to 7 to 14 days. Infected persons can become asymptomatic carriers and shed the bacteria for weeks or months, becoming the source of infection for others through poor hygiene practices. Treatment includes supportive care of symptoms. Salmonella typhi is the cause of Typhoid Fever.

Shigellosis – Associated with contaminated food and water and caused by one of four Shigella species that spreads as a result of unsanitary conditions, contaminated food and water, and overcrowded living conditions. Symptoms usually last 4 to 7 days. The illness may progress to bloody diarrhea with mucous and the constant urge to pass stools. Shigella bacteria can be shed from your gastro-intestinal system for up to 3 months after symptoms disappear. Treatment includes antibiotics.

Vibrio cholera, Vibrio parahaemolyliticus, Vibrio vulnificus
– Associated with contaminated water, raw or undercooked fish and shellfish and causes Cholera, an acute gastro-intestinal infection. Risk to travellers is low and vaccination is advised only for medical and rescue personnel working in endemic areas. The infection can lead to severe dehydration and death in undernourished persons or those with compromised immune systems or kidneys.  Vibrio vulnificus has caused septicemia (blood poisoning) in persons with liver disorders.

Viruses

Approximately 5% of Traveller’s Diarrhea is caused by viruses. A person can become ill when touching contaminated surfaces with the virus (railings, door knobs), shaking hands, or coming into close contact with an infected person and then touching your mouth and eyes.

The most common viruses causing food and water illnesses in travellers are:
Norovirus
– Associated with outbreaks at large gatherings or on cruise ships. The illness is also caused by contaminated water and foods like salads, clams, and oysters. Symptoms can appear 10 hours to 2 days after infection and include nausea, vomiting, abdominal pain, diarrhea, and sometimes fever and dehydration. The illness usually last 1 to 4 days and treatment includes supportive care of symptoms.

Rotavirus – Particularly affects children less than 5 years old and is also associated with contaminated food and water. Symptoms appear 1 to 3 days after being infected and include vomiting, diarrhea, fever, abdominal pain, and headache. Dehydration and body limpness are characteristics of this illness which typically lasts 4 to 8 days. Vaccination is recommended for children. Treatment includes supportive care of symptoms for both children and adults.

Protozoa
Approximately 10% of Traveller’s Diarrhea is caused by protozoa. In addition to contaminated food and water, these one-celled microscopic organisms are also transmitted to humans by swallowing contaminated water from lakes, rivers, fountains, ponds, and other bodies of water or accidentally swallowing soil or sand containing protozoa eggs. Typical symptoms include abdominal pain and cramps, diarrhea, bloating, nausea, lack of appetite, fatigue, headache, and light fever. Prolonged infection causes dehydration and weight loss.

The most common protozoa causing food and water illnesses in travellers are:
Amoebiasis – Caused by Entamoeba histolytica protozoa. The majority of cases are asymptomatic (persons do not exhibit symptoms). Those who do exhibit symptoms usually develop them 2 to 4 weeks after being infected. Amoebic Dysentery is the more severe form of the illness where patients develop fever and blood in their stools. In rare cases, the protozoa can cause lesions in the liver. Treatment includes taking medication belonging to the nitroimidazole family of drugs.

Cryptosporidiosis –The infection, commonly referred to as ‘Crypto’, is primarily caused by Cryptosporidium hominis protozoa. The illness is associated with contaminated food or water, including swimming pools and other water bodies. Some people are asymptomatic (do not exhibit symptoms). Those who do exhibit symptoms usually develop them 2 to 10 days after being infected. Some patients may also have a cough, recurring headache, dizziness, eye pain, and joint pain. The illness can trigger irritable bowel syndrome and inflammatory bowel diseases. Symptoms usually disappear after 1 to 2 weeks as the protozoa are shed through feces. Treatment includes anti-protozoal medication or antibiotics.

Cyclosporiasis – Caused by the Cyclospora cayetanensis protozoa and associated with fresh produce like berries and lettuce. Symptoms usually appear 2 to 7 days after infection. Some patients may develop fever after a few days. The diarrhea may come and go throughout the duration of the illness which can last from 2 to 12 weeks if untreated. The infection tends to be seasonal for reasons yet unknown and disinfecting agents like chlorine do not seem to kill the protozoa. Treatment includes taking antibiotics.   

Giardiasis–Caused by Giardia intestinalis protozoa and associated with contaminated food and water. Symptoms usually appear 1-2 weeks after infection. The symptoms usually disappear 2-4 weeks later as the protozoa are shed through feces. Treatment includes taking medication belonging to the nitroimidazole family of drugs. Treatment includes taking medication belonging to the nitroimidazole family of drugs.

Foodborne Toxins

Another source of gastro-intestinal illness are foodborne toxins produced by bacterial spores that germinate on food – particularly meat, poultry, salads, baked goods, and dairy products – that is improperly stored or refrigerated, usually standing at room temperature for a prolonged period of time.Symptoms can appear within hours of ingesting contaminated food and include abdominal pain, diarrhea, nausea, and vomiting. The infection usually lasts 1 or 2 days and treatment includes supportive care of symptoms. Antibiotics are not recommended.

Common foodborne toxins affecting travellers include:
Clostridium perfringens – Associated with meat and poultry and is the most important agent causing food poisoning in industrialized countries. Symptoms appear within 6 to 24 hours after ingestion.

Staphylococcus aureus – Associated with creamy desserts, custards, meats, and baked goods. Enterotoxins are transmitted via unsanitary practices by infected persons. Symptoms appear within 30 minutes to 8 hours after ingestion.

Clostridium botulinum – Associated with improperly canned food, lightly preserved vegetables, salted fish, and meats. Symptoms usually appear within 12 to 48 hours and include nausea, vomiting, blurred and double vision, paralysis of respiratory and motor muscles that may progress rapidly.

Seafood and Shellfish Poisoning

Seafood and shellfish poisoning occurs as a result of eating marine food products contaminated with naturally occurring toxins in sea water. Travellers are at risk in any country as a result of the availability of these products (fresh or frozen) around the world.

The most common seafood and shellfish related illnesses in travellers are:
Ciguatera Fish Poisoning – Occurs when toxins created by dinoflagellate micro-organisms are passed up the marine food chain and bio-accumulate in large fish like barracuda, grouper, red snapper, moray eel, amberjack, parrotfish, hogfish, sturgeonfish, kingfish, coral trout, and sea bass. The toxins are not destroyed through cooking, smoking, or freezing, they are odorless and tasteless, and do not alter the appearance of the fish. For information on symptoms and prevention, see Ciguatera Fish Poisoning

Scombroid Poisoning – Results from improper handling and refrigeration of fish containing high levels of natural occurring histidine (amino acid in protein). Contamination with bacteria will convert histidine to histamine causing symptoms similar to allergic reactions, which occur very rapidly and include headache, abdominal cramps, diarrhea, itching, flushed face, dry mouth, heart palpitations, difficulty breathing. Symptoms rarely last over 8 to 12 hours. Scombroid poisoning affects fish from the Scombridae family: Tuna, mackerel, skipjack, and bonito. It can also affect other species such as herring, bluefish, sardine, anchovy, amberjack, and mahi-mahi. Treatment includes taking anti-histamines and supportive care of symptoms. Treatment in severe cases may include anti-inflammatory steroids and epinephrine related medication.

Shellfish Poisoning – Associated with the algal blooms (red tides) occurring in temperate and tropical areas. Oysters, clams, cockles, mussels, scallops, crabs, and lobsters filter or ingest toxins produced by dinoflagellates micro-organisms. There are four different illnesses associated with shellfish poisoning:

  1. Diarrheic shellfish poisoning can occur hours or days after eating contaminated shellfish. Symptoms include abdominal pain, nausea, vomiting, and diarrhea. Recovery occurs within 2 to 3 days and treatment includes supportive care of symptoms.
  2. Neurotoxic shellfish poisoning can occurs 1 to 6 hours after ingestion. Symptoms include nausea, vomiting, diarrhea, reversal of hot and cold temperature sensation, and involuntary muscle movement. Recovery occurs within 2 to 3 days and includes supportive care of symptoms.
  3. Paralytic shellfish poisoning can occur 30 minutes after eating contaminated shellfish. Symptoms include nausea, numbness of face arms and legs, headache, loss of coordination and dizziness. In severe cases respiratory failure and paralysis may lead to death.
  4. Amnesic shellfish poisoning can occur within 24 hours of ingestion and include nausea, vomiting, abdominal pain, and diarrhea. Within 48 hours, symptoms include headache, seizures, muscle weakness or paralysis, and disorientation. Permanent short-term memory loss has been observed, and in severe cases can lead to coma or death. Treatment includes supportive care of symptoms.

Puffer (Fugu) Fish Poisoning – Caused by a tetrodotoxin accumulating mainly in the liver, intestines and ovaries of puffer fish, ocean sunfish, globe fish, and porcupine fish. Symptoms appear between 6 and 20 hours and include nausea, abdominal pain, diarrhea, vomiting, profuse sweating, salivation, headache, hypothermia, heart palpitation. Neurological symptoms include numbness, loss of coordination, tremors, and paralysis. The illness can also cause respiratory failure and approximately 60% of patients die. Treatment involves supportive care of symptoms and may include cholinesterase inhibitors (anti-poisoning agents).

Travel and Mental Health

Travel is enjoyable, but there is no doubt that it can be stressful. Even if you don't have a prior history of mental illness, travel stress, mood changes, anxiety and other mental health concerns can unexpectedly affect you and potentially disrupt your trip. Studies show that psychiatric emergencies are the leading cause for air evacuations along with injuries and cardiovascular disease.

Factors Affecting Mental Health During Travel

Your mental and physical health prior to, and during, a trip determines how well you will cope with travel stress. Consider the following:

  • Tiredness, lack of sleep.
  • Major life events occurring prior to travel such as a birth, death, wedding, divorce, moving, or serious illness.
  • Difficult home or professional life; experiencing recent emotional exhaustion or financial strain.
  • Being lonely; prone to depression and anxiety.
  • Having pre-existing psychiatric, behavioural, neurological disorders; memory or cognitive deficits.
  • Dependence on, or misuse, of psychoactive substances.
  • Using medications that have psychiatric or neurological side effects (some anti-retrovirals and anti-malarials).
  • Type and length of travel; adventure, business, leisure, emergency aid work, missions.
  • Travel destination; travelling to politically unstable or war-torn areas, returning to a place where psychological trauma occurred.

Mental Health Abroad

Mental illness is an under recognized public health concern and travellers often have difficulty accessing adequate emergency psychiatric care abroad. While some countries are leading the way in mental healthcare and treatment, 30% of countries do not have a budget dedicated to mental health and 64% do not have any mental health legislation or it's outdated.

Accessibility to a psychiatrist varies from more than 10 per 100,000 to fewer than 1 per 300,000 people. Almost 70% of psychiatric beds are in mental hospitals rather than general hospitals or in integrated community care facilities.*

Persons with mental health concerns have the additional burden of dealing with stigma ? negative attitudes and behaviour towards their illness. Prejudice and discrimination towards mental illness may determine the type of medical care you will receive abroad.

* World Health Organization: Mental Health, Human Rights and Legislation Framework.
 

Download My Travel and Mental Health Checklists

What's inside:

  • Tips for coping with travel stress.
  • Tips for travellers with no prior history of mental illness.
  • Tips for travelling with medications.
  • Tips for travellers with:
    • Mood disorders (depression, bipolar disorder)
    • Anxiety disorders (panic attacks, phobias, obsessive compulsive disorders, posttraumatic stress disorder)
    • Psychotic disorders (acute situational psychosis, schizophrenia)
    • Substance dependence

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